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Step
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Name
*
First
Middle
Last
SSN
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Email
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DOB
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Gender
*
– Select –
Male
Female
Job Title
*
Resident State
– Select –
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Insurance License #:
Are you currently a registered representative with FINRA (IE: hold series exams)?
*
Yes
No
Business Phone
*
Mobile
*
Fax
Residential Address (NO P.O. Boxes):
*
Address Line 1
City
– Select –
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
When did you start living at this address:
*
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YYYY
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2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2006
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2004
2003
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Business Address (NO P.O. Boxes):
*
Address Line 1
City
– Select –
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What is your Preferred Mailing Address?
*
Residential
Business
Who referred you to our brokerage platform?
Next
Contracting Type:
*
Individual
Agency
Solicitor / LOA
Do you have a National Account Affiliation? If yes, please identify:
If you have selected Agency or Solicitor/LOA, complete the Agency Information section below:
EIN#:
*
Agency Name:
*
Principal Name:
*
Principal Title:
*
Agency Phone:
Agency Fax:
Agency Email:
Agency Website:
Agency Address (No P.O. Boxes):
*
Address Line 1
City
– Select –
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Broker/Dealer Name:
CRD #:
Previous
Next
Legal Questions for Contracting and Appointment Requests
Please answer the following questions. If you answer YES to any question, be sure to provide a full, detailed explanation including specific dates. Attach additional documentation if necessary at the bottom of this page.
1. Have you ever been charged or convicted of or plead guilty or no contest to any Felony, Misdemeanor, federal/state insurance and/or securities or investments regulations or statutes? Have you ever been on probation?
*
Yes
No
1a. Have you ever been convicted of or plead guilty or no contest to any Felony?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
1b. Have you ever been convicted of or plead guilty or no contest to any Misdemeanor?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
1c. Have you ever been convicted of or plead guilty or no contest to a violation of federal or state securities or investment related regulations?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
1d. Have you ever been convicted of or plead guilty or no contest to a violation of state insurance department regulation or statutes?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
1e. Has any foreign government, court, regulatory agency, or exchange ever entered an order against you related to investments or fraud?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
1f. Have you ever been charged with a Felony?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
1g. Have you ever been charged with a Misdemeanor?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
1h. Have you ever been on probation?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
2. Have you ever been or are you currently being investigated, have any pending indictment, lawsuits, or have you ever been in a lawsuit with an insurance company?
*
Yes
No
2a. Are you currently under investigation by any legal or regulatory authority?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
2b. Have you been under investigation by any insurance company?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
2c. Have you ever been or are you currently involved in any pending indictments, lawsuits, civil judgments or other legal proceedings (civil or criminal)(you may omit family court).
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
2d. Have you ever been named as a defendant or codefendant in a lawsuit, or have you ever sued or been sued by an insurance company?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
3. Have you ever been alleged to have engaged in any fraud?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
4. Have you ever been found to have engaged in any fraud?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
5. Has any insurance or financial services company or broker-dealer terminated your contract or appointment or permitted you to resign for a reason other than lack of sales?
*
Yes
No
5a. Were you fired because you were accused of violating insurance or investment related statutes, regulations, rules or industry standards of conduct?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
5b. Were you fired because you were accused of fraud or the wrongful taking of property?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
5c. Failure to supervise in connection with insurance or investment related statutes, regulations, rules or industry standards of conduct?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
6. Have you ever had an appointment with any insurance company denied or terminated for cause?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
7. Does any insurer, insured, or other person claim any commission chargeback or other indebtedness from you as a result of any insurance transactions or business?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
8. Has any lawsuit or claim ever been made against you, your surety company, or errors and omissions insurer arising out of your sales or practices, or, have you been refused surety bonding or E&O coverage?
*
Yes
No
8a. Has a bonding or surety company ever denied, paid on or revoked a bond for you?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
8b. Has any Errors & Omissions (E&O) carrier ever denied, paid claims on or cancelled your coverage?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
9. Have you ever had an insurance or securities license denied, suspended, cancelled or revoked?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
10. Has any state or federal regulatory body found you to have been a cause of an investment – or insurance – related business having its authorization to do business denied, suspended, revoked, or restricted?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
11. Has any state or federal regulatory agency revoked or suspended your license as an attorney, accountant, or federal contractor?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
12. Has any state or federal regulatory agency found you to have made a false statement or omission or been dishonest, unfair, or unethical?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
13. Have you had any interruptions in licensing?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
14. Has any state, federal or self-regulatory agency filed a complaint against you, fined, sanctioned, censured, penalized or otherwise disciplined you for a violation of their regulations or state or federal statutes? Have you ever been the subject of a consumer initiated complaint?
*
Yes
No
14a. Has any regulatory body ever sanctioned, censured, penalized or otherwise disciplined you?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
14b. Has any state, federal, or self-regulatory agency filed a complaint against you, fined or sanctioned you?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
14c. Have you ever been the subject of a consumer initiated complaint?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
15. Have you personally or any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or declared bankruptcy?
*
Yes
No
15a. Have you personally filed a bankruptcy petition or declared bankruptcy?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
15b. Has any insurance or securities brokerage firm with whom you have been associated filed a bankruptcy petition or been declared bankrupt either during your association or within five years after termination of such association?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
15c. Is the bankruptcy pending?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
16. Are there any unsatisfied judgments, garnishments or liens against you?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
17. Are you connected in any way with a bank, savings & loan association, or other lending or financial institution?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
18. Have you ever used any other names or aliases?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
19. Do you have any unresolved matters pending with the Internal Revenue Service or other taxing authority?
*
Yes
No
Date of Action
*
Action
*
Reason
*
Explanation
*
If you answered any questions YES, provide an explanation that includes dates, actions, and descriptions. Upload below.
Click or drag files to this area to upload.
You can upload up to 10 files.
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Next
Direct Deposit – Electronic Fund Transfers (EFT)
Individual Contracting?
Account must be under
Your Name.
OR
Agency Contracting?
Account must be under the
Agency Name.
Account Owner Name
*
Transit/Routing #
*
Account #
*
Account Type
*
Checking
Savings
Financial Institution Name
*
Bank Address
Address Line 1
City
– Select –
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
By signing below, I herby authorize the Company to initiate credit entries and, if necessary, adjustments for credit entries in error to the checking and/or savings account indicated on this form. This authority is to remain in full effect until the company has received written notification from me of its termination. I understand that this authorization is subject to the terms of any agent or representative contract, commission agreement, or loan agreement that I may have now, or in the future, with the Company.
*
Clear Signature
Date
*
Please attach a copy of a VOIDED CHECK or a LETTER FROM YOUR BANK on Bank letterhead confirming Account Name, Account #, & Transit/Routing #.
*
Click or drag a file to this area to upload.
DIRECT DEPOSIT AGREEMENT & AGREEMENT TO REPAY COMMISSIONS PAID TO
Name
*
First
Last
BY Risk & Insurance Associates and affiliate companies (Barnum Financial Group, LLC & Barnum Benefit Advisors, LLC)
SSN/TIN
*
I (the Signature Authorizer above) hereby authorize Risk & Insurance Associates and affiliate companies to initiate automatic deposits to my account listed on the Direct Deposit – Electronic Funds Transfers (EFT) form and agrees to repay to Risk & Insurance Associates and affiliate companies any and all commission paid to me by Risk & Insurance Associates and affiliate companies in the event the policy is returned, there is a reduction in face amount, there is a policy recission, a charge back by the insurance carrier for any reason or an overpayment error occurs. Further, I agree not to hold Risk and Insurance Associates or affiliate companies responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.
*
Clear Signature
Date
*
Previous
Next
Errors & Omissions Coverage (E&O)
Upload a copy of your OR your agency’s E&O Insurance Certificate of Coverage
IMPORTANT
Whether you are covered under an Individual or Group E&O policy, the E&O Certificate MUST list your Full Name as the Insured.
CORRECT
My Insurance Agency Inc. Joe Agent 123 Main Ave. City, State 12345
INCORRECT
My Insurance Agency Inc. 123 Main Ave. City, State 12345
***If your name is not listed correctly, please provide a letter from the E&O Carrier listing the agent(s) covered under the policy.***
File Upload
*
Click or drag a file to this area to upload.
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Next
Please use the upload fields below to add any additional documentation in regards to your contracting request: – Copy of AML Completion Certificate (within the last 2 years) – Training Completion Certificates (LTC, Carrier Product Training, etc…) – Additional verifications based on legal questions
Click or drag files to this area to upload.
You can upload up to 10 files.
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I hereby authorize SuranceBay, LLC and its general agency customers (the “Authorized Parties”) to affix or append a copy of my signature, as set forth below, to any and all required signature fields on forms and agreements of any insurance carrier (a “Carrier”) designated by me through the SureLC software or through any other means, including without limitation, by e-mail or orally. The Authorized Parties shall be permitted to complete and submit all such forms and agreements on my behalf for the purpose of becoming authorized to sell Carrier insurance products. I hereby release, indemnify and hold harmless the Authorized Parties against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which they may sustain or incur as a result of carrying out the authority granted hereunder. </br> By my signature below, I certify that the information I have submitted to the Authorized Parties is correct to the best of my knowledge and acknowledge that I have read and reviewed the forms and agreements which the Authorized Parties have been authorized to affix my signature. I agree to indemnify and hold any third party harmless from and against any and all claims, demands, losses, damages, and causes of action, including expenses, costs and reasonable attorneys' fees which such third party may incur as a result of its reliance on any form or agreement bearing my signature pursuant to this authorization.
*
Clear Signature
Type your First and Last Name below:
*
First
Last
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